The present invention generally relates to electrosurgical systems and methods for ablating, severing, dissecting, contracting, or otherwise modifying target tissues or organs. The invention relates more particularly to electrosurgical apparatus and methods for modifying a tissue or organ via molecular dissociation of tissue components, wherein the apparatus includes an active electrode in the form of a plasma blade or hook. The present invention further relates to electrosurgical instruments and methods for harvesting blood vessels such as the internal mammary artery, the saphenous vein, or the like, for use in coronary artery bypass graft procedures.
Conventional electrosurgical instruments and techniques are widely used in surgical procedures because they generally reduce patient bleeding and trauma associated with cutting operations, as compared with mechanical cutting and the like.
Conventional electrosurgical procedures may be classified as operating in monopolar or bipolar mode. Monopolar techniques rely on external grounding of the patient, where the surgical device defines only a single electrode pole. Bipolar devices have two electrodes for the application of current between their surfaces. Conventional electrosurgical devices and procedures, however, suffer from a number of disadvantages. For example, conventional electrosurgical cutting devices typically operate by creating a voltage difference between the active electrode and the target tissue, causing an electrical arc to form across the physical gap between the electrode and the tissue. At the point of contact of the electric arcs with the tissue, rapid tissue heating occurs due to high current density between the electrode and the tissue. This high current density causes cellular fluids to rapidly vaporize into steam, thereby producing a “cutting effect” along the pathway of localized tissue heating. Thus, the tissue is parted along the pathway of evaporated cellular fluid, inducing undesirable collateral tissue damage in regions surrounding the target tissue.
Further, monopolar electrosurgical devices generally direct electric current along a defined path from the exposed or active electrode through the patient's body to the return electrode, the latter externally attached to a suitable location on the patient. This creates the potential danger that the electric current will flow through undefined paths in the patient's body, thereby increasing the risk of unwanted electrical stimulation to portions of the patient's body. In addition, since the defined path through the patient's body has a relatively high electrical impedance, large voltage differences must typically be applied between the return and active electrodes in order to generate a current suitable for ablation or cutting of the target tissue. This current, however, may inadvertently flow along body paths having less impedance than the defined electrical path, which will substantially increase the current flowing through these paths, possibly causing damage to or destroying surrounding tissue.
Bipolar electrosurgical devices have an inherent advantage over monopolar devices because the return current path does not flow through the patient. In bipolar electrosurgical devices, both the active and return electrode are typically exposed so that both electrodes may contact tissue, thereby providing a return current path from the active to the return electrode through the tissue. One drawback with this configuration, however, is that the return electrode may cause tissue desiccation or destruction at its contact point with the patient's tissue. In addition, the active and return electrodes are typically positioned close together to ensure that the return current flows directly from the active to the return electrode. The close proximity of these electrodes generates the danger that the current will short across the electrodes, possibly impairing the electrical control system and/or damaging or destroying surrounding tissue.
In addition, conventional electrosurgical methods are generally ineffective for ablating certain types of tissue, and in certain types of environments within the body. For example, loose or elastic connective tissue, such as the synovial tissue in joints, is extremely difficult (if not impossible) to remove with conventional electrosurgical instruments because the flexible tissue tends to move away from the instrument when it is brought against this tissue. Since conventional techniques rely mainly on conducting current through the tissue, they are not effective when the instrument cannot be brought adjacent to, or in contact with, the elastic tissue for a sufficient period of time to energize the electrode and conduct current through the tissue.
A prevalent form of cardiovascular disease is atherosclerosis in which the cardiovascular system leading to the heart is damaged or obstructed as a result of occluding material in the blood stream. Vascular complications produced by atherosclerosis, such as stenosis, aneurysm, rupture, or occlusion, increase the likelihood of angina, stroke, and heart attacks. In many cases, the obstruction of the blood stream leading to the heart can be treated by a coronary artery bypass graft (CABG) procedure.
In a conventional CABG procedure, the obstruction is bypassed by a vascular conduit established between an arterial blood source and the coronary artery to a location beyond the obstruction. The vascular conduit is typically a non-critical artery or vein harvested from elsewhere in the body. In a procedure known as “free bypass graft”, the saphenous vein is harvested from the patient's leg and is used as the vascular conduit. One end of the saphenous vein is anastomosed to the aorta and the other end is anastomosed to the diseased coronary artery at a location past the obstruction. In a procedure known as “in situ bypass graft”, an internal mammary artery (IMA) is used as the bypass conduit. In an in situ bypass graft procedure, the surgeon dissects a sufficient length of the artery from its connective tissue, then transects the artery and connects the transected end to the diseased coronary past the obstruction, and leaves the other end of the IMA attached to the arterial supply.
The internal mammary arteries are particularly desirable for use as in situ bypass grafts, as they are conveniently located, have diameters and blood flow volumes that are comparable to those of coronary arteries, and have superior patency rates. Use of the left or right IMA as a bypass graft first involves harvesting the IMA from the inside chest wall.
In conventional CABG procedures, access to the IMA is typically obtained either through a sternotomy or a gross thoracotomy. In the sternotomy or gross thoracotomy, the surgeon typically uses a saw or other cutting instrument to cut the sternum longitudinally to allow two opposing halves of the anterior portion of the rib cage to be spread apart. The opening into the thoracic cavity is created so that the surgeon may directly visualize the heart and thoracic cavity. However, such methods suffer from numerous drawbacks. For example, the longitudinal incision in the sternum often results in bone bleeding, which is difficult to stop. The bone bleeding can produce a high degree of trauma, a larger risk of complications, an extended hospital stay, and a painful recovery period for the patient. Once the surgeon has accessed the thoracic cavity, the conventional method of harvesting the IMA involves the use of scalpels or conventional electrosurgical devices. A number of disadvantages inherent in conventional electrosurgical devices have been set forth hereinabove.
Thus, there is a need for an electrosurgical apparatus which can be used for the precise removal or modification of tissue at a specific location, wherein a target tissue or organ can be dissected, transected, incised, contracted, and/or coagulated, with minimal, or no, collateral tissue damage. The instant invention provides such an apparatus and related methods, wherein tissue may be ablated or otherwise modified by a first region or element of a blade active electrode, and the modified tissue can be further modified by a second region or element of the blade active electrode, and wherein the quantity and quality of the tissue modification can be accurately controlled.